Highmark Cms-1500 Instructions

Finding out how to fill in the CMS-1500 claim form correctly can help you avoid delaying your patient’s health insurance claim. The Highmark CMS-1500 claim form is used to submit a paper claim on behalf of your Medicare patients. The claim form has 33 major fields, some of which contain multiple sub-fields. You must fill in the form correctly so that the insurance company can deal with the claim in a timely fashion. The CMS-1500 form is approved by the National Uniform Claim Committee.

Things You'll Need

• Red pen

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Instructions

• 1

  Fill in all of the fields in red ink. This has to be done because the form is read by an image processor, and red ink is picked up more efficiently by the machine. Do not fill out the form in any other color ink under any circumstances.

• 2

  Write an “X” in the relevant box in Section 1, which is located in the top left-hand corner of the form. This field shows the type of health insurance coverage that is relevant to the particular claim you are filing. Write the patient’s Health Insurance Claim Number in Section 1a, located to the right of Section 1.

• 3

  Fill in your patient’s personal details in sections 2, 3, 5, 6 and 8. Put an “X” in the Self Box of Section 6 if your patient is the person who is insured. Write the details of the insured party in sections 4 and 7. If the insured party is the patient, just write “Same” in both boxes.

• 4

  Fill in the details of other people enrolled in a Medigap policy in Section 9 if it isn’t the primary patient. If it is the primary patient (whose details are in Section 2), write “Same” in the field. If the patient doesn’t have Medigap benefits, then leave the section blank. If the Medigap insurer doesn’t have a PayerID number, enter the insurance plan name or the Medigap insurance program.

• 5

  Answer all questions in section 10a through 10c by putting “X” marks in the relevant boxes. Put the patient’s Medicaid number in section 10d if they are entitled to Medicaid. Remember to write “MCD” before the number.

• 6

  Fill in the main insured party’s policy or group number in Section 11 if the insurance is primary to Medicare. Otherwise, write “None” in this box. If your patient did have Medicare insurance, but it has been terminated, fill in sections 11b and 11c. Fill in sections 11a to 11c if the patient’s insurance is primary to Medicare. You can leave Section 11d blank.

• 7

  Sign and date Section 12 and get the insured person to sign in Section 13. Fill in sections 14 to 24 with the details of the illness and costs incurred as requested. Enter the service provider’s Federal Tax ID Number in Section 25, and leave Section 26 blank if you don’t know it. Place an “X” in the relevant box in Section 27 to show whether the service provider accepts the assignment of Medicare benefits.

• 8

  Fill in the remaining cost details in sections 28 to 30. The provider of the service must sign and date Section 31. Enter the address of the location of the medical service (the specific hospital, for example) in Section 32. Write the physician or supplier’s billing name, address, ZIP code and telephone number in Section 33.